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43 43. Mant J, Hobbs FDR, Fletcher K, et al. Warfarin versus aspirin for stroke prevention in an elderly community population with atrial fibrillation (the Birmingham Atrial Fibrillation Treatment of the Aged Study, BAFTA): a randomised controlled trial. Lancet. 2007; 370:493–503.

44 44. Sharma M, Cornelius VR, Patel JP, et al. Efficacy and harms of direct oral anticoagulants in the elderly for stroke prevention in atrial fibrillation and secondary prevention of venous thromboembolism: systematic review and meta‐analysis. Circulation. 2015; 132:194–204.

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Domenico Fusco, Andrea Bellieni, Beatrice Di Capua, and Giuseppe Colloca

Fondazione Policlinico Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy

The myelodysplastic syndromes (MDSs) are a heterogeneous group of malignant hematopoietic stem cell disorders characterized by cytopenia due to dysplastic and ineffective blood cell production and potential variable risk of transformation to acute leukaemia. 1,2These disorders are sporadic and arise de novo or may result after exposure to certain forms of environmental toxins (e.g. benzene), radiation (e.g. therapeutic or accidental), and chemotherapy exposure as alkylating agents (secondary MDS). 3,4MDS primarily affects older patients, with an onset mean age over 70 and an increased incidence with advancing age. 5,6The secondary MDSs are not age‐related, although they are extremely rare in children, where monocytic leukaemia can be observed. The incidence has increased over time because of the increased recognition of this disease by medical doctors, as well as the ageing of the population. The demographics in developed countries shift toward older patient populations due to increased longevity and better quality of healthcare, so more people are receiving intensive treatments like chemotherapy.

MDS may easily be overlooked in elderly patients. It can present simply as a chronic macrocytic anaemia, and there may be a tendency to ‘leave well enough alone’ in an older patient with multiple comorbidities.

However, our understanding of MDS continues to improve, so we can use geriatric knowledge in assessing complex older and oldest‐old patients, to recognize and measure frailty and identify fit and the unfit patients. Better treatment strategies have been developed to prolong life and delay transformation to acute leukaemia, reducing the risk of major complications such as anaemia, bleeding, and severe infections. The majority of patients cannot tolerate intensive therapeutic approaches such as allogeneic hematopoietic stem cell transplantation. For this reason, treatment needs to be risk‐adapted and tailored to the frail old patient, involving the definition of different goals of therapy according to the risk status of the patient. 7

Myelodysplastic syndromes are the most common hematologic neoplasms in the elderly, and the incidence of MDS in the US is expected to double from 2000 to 2030 as the result of population ageing. 8,9